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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47829/psn-pdf
    March 27, 2019 - The impact of internal service quality on preventable adverse events in hospitals. March 27, 2019 Zheng S, Tucker AL, Ren ZJ, et al. The Impact of Internal Service Quality on Preventable Adverse Events in Hospitals. Production Operations Manag. 2017;27(12):2201-2212. doi:10.1111/poms.12758. https://psnet.ahrq.gov/…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34902/psn-pdf
    February 27, 2009 - Hospital rules-based system: the next generation of medical informatics for patient safety. February 27, 2009 Wilson JW, Oyen LJ, Ou NN, et al. Hospital rules-based system: the next generation of medical informatics for patient safety. Am J Health Syst Pharm. 2005;62(5):499-505. https://psnet.ahrq.gov/issue/hospit…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842431/psn-pdf
    January 11, 2023 - Confronting racism in pediatric care. January 11, 2023 Danielson B. Confronting racism in pediatric care. Health Affairs. 2022;41(11):1681-1685. doi:10.1377/hlthaff.2022.01157. https://psnet.ahrq.gov/issue/confronting-racism-pediatric-care Racism is a patient safety issue that is gaining the increased attention ne…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837153/psn-pdf
    January 01, 2025 - Annual Communication, Apology, and Resolution (CARe) Forum. October 29, 2024 Betsy Lehman Center for Patient Safety.  https://psnet.ahrq.gov/issue/annual-communication-apology-and-resolution-care-forum Communication and resolution programs are a promising strategy for successful management of relationships a…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34660/psn-pdf
    December 24, 2008 - Building a learning organization. December 24, 2008 Garvin DA. Building a learning organization. Harv Bus Rev. 1993;71(4):78-91. https://psnet.ahrq.gov/issue/building-learning-organization Garvin, a Harvard Business School professor, postulates that for organizations to truly improve over time and succeed, they ne…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837907/psn-pdf
    August 24, 2022 - ISMP Guidelines for Safe Medication Use in Perioperative and Procedural Settings. August 24, 2022 Plymouth Meeting, PA: Institute for Safe Medication Practices; 2022. https://psnet.ahrq.gov/issue/ismp-guidelines-safe-medication-use-perioperative-and-procedural-settings Medication errors associated with surgery and…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47386/psn-pdf
    September 19, 2018 - Active-shooter response at a health care facility. September 19, 2018 Inaba K, Eastman AL, Jacobs LM, et al. Active-Shooter Response at a Health Care Facility. N Engl J Med. 2018;379(6):583-586. doi:10.1056/NEJMms1800582. https://psnet.ahrq.gov/issue/active-shooter-response-health-care-facility Physical and verbal…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39977/psn-pdf
    November 03, 2010 - Structural empowerment and patient safety culture among registered nurses working in adult critical care units. November 3, 2010 Armellino D, Griffin MTQ, Fitzpatrick JJ. Structural empowerment and patient safety culture among registered nurses working in adult critical care units. J Nurs Manag. 2010;18(7):796-803…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45223/psn-pdf
    September 27, 2017 - Hospital safety climate and safety behavior: a social exchange perspective. September 27, 2017 Ancarani A, Di Mauro C, Giammanco MD. Hospital safety climate and safety behavior: A social exchange perspective. Health Care Manage Rev. 2017;42(4):341-351. doi:10.1097/HMR.0000000000000118. https://psnet.ahrq.gov/issue…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39978/psn-pdf
    November 03, 2010 - Creating an improvement culture for enhanced patient safety: service improvement learning in pre-registration education. November 3, 2010 Christiansen A, Robson L, Griffith-Evans C. Creating an improvement culture for enhanced patient safety: service improvement learning in pre-registration education. J Nurs Manag…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42506/psn-pdf
    August 28, 2013 - Foundations for teaching surgeons to address the contributions of systems to operating room team conflict. August 28, 2013 Rogers DA, Lingard LA, Boehler ML, et al. Foundations for teaching surgeons to address the contributions of systems to operating room team conflict. Am J Surg. 2013;206(3):428-32. doi:10.1016/…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38459/psn-pdf
    October 03, 2012 - Identifying opportunities for quality improvement in surgical site infection prevention. October 3, 2012 Gagliardi AR, Eskicioglu C, McKenzie M, et al. Identifying opportunities for quality improvement in surgical site infection prevention. Am J Infect Control. 2009;37(5):398-402. doi:10.1016/j.ajic.2008.10.027. h…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44718/psn-pdf
    November 25, 2015 - Beyond the Quick Fix: Strategies for Improving Patient Safety. November 25, 2015 Baker GR. Toronto, ON: Institute of Health Policy, Management and Evaluation, University of Toronto; 2015. https://psnet.ahrq.gov/issue/beyond-quick-fix-strategies-improving-patient-safety The 2004 Canadian Adverse Events Study helpe…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46636/psn-pdf
    January 24, 2018 - Drug shortages continue to compromise patient care. January 24, 2018 ISMP Medication Safety Alert! Acute Care Edition. January 11, 2018;23:1-4. https://psnet.ahrq.gov/issue/drug-shortages-continue-compromise-patient-care Drug shortages are known to disrupt the safety of care. This newsletter article reports the res…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72786/psn-pdf
    February 24, 2021 - Drug shortages amid the COVID-19 pandemic. February 24, 2021 Bookwalter CM. US Pharmacist. 2021;46(2):25-28.    https://psnet.ahrq.gov/issue/drug-shortages-amid-covid-19-pandemic COVID-19 has increased uncertainties in sectors across health care. This article discusses a variety of supply-chain fact…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38036/psn-pdf
    January 02, 2017 - Debriefing medical teams: 12 evidence-based best practices and tips. January 2, 2017 Salas E, Klein C, King HB, et al. Debriefing medical teams: 12 evidence-based best practices and tips. Jt Comm J Qual Patient Saf. 2008;34(9):518-527. https://psnet.ahrq.gov/issue/debriefing-medical-teams-12-evidence-based-best-pr…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73996/psn-pdf
    October 29, 2021 - Patient, Medical, and Legal Perspectives of Unsafe Care. October 20, 2021 Patient Safety Movement. October 29, 2021.  https://psnet.ahrq.gov/issue/patient-medical-and-legal-perspectives-unsafe-care Effective response to medical harm involves a variety of perspectives that are aligned in purpose. This webinar …
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60533/psn-pdf
    May 27, 2020 - What constitutes effective team communication after an error? May 27, 2020 Hart WM, Doerr P, Qian Y, et al. What constitutes effective team communication after an error? AMA J Ethics. 2020;22(4):E298-E304. doi:10.1001/amajethics.2020.298. https://psnet.ahrq.gov/issue/what-constitutes-effective-team-communication-a…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60288/psn-pdf
    April 29, 2020 - Do some surgical implants do more harm than good? April 29, 2020 Groopman J. New Yorker Online. April 13, 2020.  https://psnet.ahrq.gov/issue/do-some-surgical-implants-do-more-harm-good Medical devices support quality of life but must be designed appropriately and managed carefully to ensure safety over time.…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39108/psn-pdf
    November 18, 2009 - Missed opportunities to initiate endoscopic evaluation for colorectal cancer diagnosis. November 18, 2009 Singh H, Daci K, Petersen L, et al. Missed opportunities to initiate endoscopic evaluation for colorectal cancer diagnosis. Am J Gastroenterol. 2009;104(10):2543-2554. doi:10.1038/ajg.2009.324. https://psnet.a…

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